When the First Nose Job Was Not the Last Word: Revision Rhinoplasty With Dr. Agullo
A fair number of rhinoplasty consultations at Southwest Plastic Surgery begin with a nose that has already been operated on somewhere else.
The story is consistent: the surgery went fine, the recovery went fine, and then over the months the bump crept back. Patients arrive assuming the first surgeon failed. Dr. Frank Agullo usually has different news.
“In a revision, the bump is often not the original bump,” he explains. “It is scar tissue that formed over the area we worked on, and thick skin is the reason it stays. Thick skin has memory.”
Why Bumps Come Back
“Thick skin has memory,” Dr. Agullo says. “It wants to drape back over the old contour, and if it has anything to hold on to, it will re-create the shape you were trying to get rid of. That is why I look at your skin before I look at anything else. Healthy skin is what lets me go back in safely.”
A tip that healed well the first time is one of the most reassuring signs he looks for.
The Filler Answer, Refused
Patients often arrive having read that nasal filler, the so-called liquid nose job, can camouflage the bump without surgery. Dr. Agullo declines, every time.
“Filler is going to make your nose bigger. All we do with filler is cheat by adding to other places, so instead of lowering the bump, we build up everything around it,” he says. “And what we see now is that filler in the nose does not really go away. It spreads. It ends up on the sides, and in the end it makes you look wide. That is the opposite of what almost everybody who walks into my office is asking for.”
What he will offer is Kenalog, a steroid injection that can soften dorsal scar tissue. “They often give partial improvement, and they are a reasonable way to see how much a bump will respond before you commit to surgery. But no, there is nothing stronger. And I would not inject something like Kybella into the nose, because it can eat up things other than fat.”
What a Revision Involves
“I have to go through there to look at it,” Dr. Agullo says. “Otherwise it is blind surgery, and blind surgery is how you end up with an irregularity you cannot explain.”
Working under direct vision, he carves out the scar tissue and shaves the dorsum down. “Because thick skin has memory and wants to re-drape over the old shape, I am not aiming for a perfectly flat line. I am aiming for a slight depression, so that once the skin settles back down, it reads as narrow instead of wide.” Internal sutures may tuck the skin envelope down so the bump does not pop back, and the dressing approach changes from the first surgery.
Timing is part of the technique. “I would rather wait and do it once than rush and do it twice.”
The Broken Nose Is Its Own Operation
For patients whose nose is fractured and deviated, sometimes with one side barely moving air, the operation is a septorhinoplasty: re-fracture, reposition, straighten the septum. Breathing is the first goal, the profile second, and both are usually handled in one surgery, planned with 3D imaging.
| Septorhinoplasty at a Glance | |
|---|---|
| Anesthesia | General, outpatient |
| Duration | 2 to 2.5 hours |
| Pain | Usually minimal |
| Splints removed | About one week |
| Final result | Six weeks, refining over a year |
| Septal perforation risk | Under one percent |
The risks are stated before surgery, not after: a septal perforation rate under one percent, and the reality that the nose keeps growing through life, so even a perfectly set nose can shift slightly with the years. The breathing improvement holds.
The Chin, Considered Alongside
Profiles are read whole, which is why chin projection comes up in rhinoplasty consultations. A recessed chin makes any nose look larger. A solid silicone chin implant projects the chin forward, improves the neckline, and shrinks the nose visually without touching it. When the septum is already being repaired, adding the implant in the same operation is straightforward.
The Surgeon for the Second Try
Dr. Frank Agullo is the founder of Southwest Plastic Surgery in El Paso, Texas: double board-certified by the American Board of Plastic Surgery and the American Board of Surgery, a Fellow of the American College of Surgeons, a Mayo Clinic plastic surgery fellowship alum, and a Castle Connolly Top Doctor for thirteen consecutive years.
Revision rhinoplasty is among the most demanding work in the specialty, scarred tissue, altered anatomy, skin with a memory, and it is exactly where his refusal to shortcut with filler matters most. If the shape is wrong, the shape gets fixed.
For Dr. Agullo’s editorial take, read the companion piece on drworldwide.com. For the clinical Q&A, see agulloplasticsurgery.com.
Ready to Talk?
If your bump came back or your nose never breathed right, schedule a consultation at Southwest Plastic Surgery for an honest assessment. Call (915) 590-7900, text 1-866-814-0038, or book online at agulloplasticsurgery.com. #StayBeautiful
@RealDrWorldWide on Instagram, TikTok, and Snapchat, @Agullo on X, or @AgulloPlasticSurgery on Facebook.
